The impact of media-based mental health campaigns on male help-seeking: a systematic review

Abstract More than half of all men do not seek professional help for depression, suicide and anxiety. Although media-based campaigns represent a promising health promotion intervention to improve male help-seeking, it is unclear what communication strategies in extant mental health media-based campaigns are effective for men. The aim of this systematic review was to synthesize information about the effectiveness of these campaigns on male help-seeking outcomes. A search was conducted of electronic databases and gray literature. Studies were eligible if they examined the effectiveness of a media-based campaign targeting male help-seeking attitudes, beliefs, intentions or behaviors in relation to mental disorders, distress, suicide or self-harm. Twenty-two studies of varying quality met the eligibility criteria. Most studies targeting mental health or depression were found to positively influence male help-seeking. There were mixed results for suicide prevention campaigns. Some evidence suggests that overall, brochure-based campaigns impact help-seeking. The use of male or mixed-gender campaign imagery produced similar results. The choice of message framing appeared to influence help-seeking outcomes. Despite substantial heterogeneity in campaign approaches and difficulties isolating the effects of campaign delivery from messaging, the review indicates that media-based campaigns can play a role in improving male help-seeking for mental health difficulties. Mounting evidence suggests that messaging and delivery should align with male communication preferences. However, high-quality, targeted research is required to evaluate the circumstances in which various campaign delivery and messaging components are effective in improving male help-seeking for poor mental health and suicidality.


INTRODUCTION
An estimated 60% of adult males experiencing depression, anxiety or suicidality do not engage with mental health professionals (Australian Institute of Family Studies [AIFS], 2020).Although mental disorders are more prevalent among females (24.6%) than males (18.3%) over 12 months (Australian Bureau of Statistics [ABS], 2023b), males account for more than three-quarters of suicides in high-income countries (ABS, 2023a; Centers for Disease Control and Prevention, 2023).Similarly, males aged 16-85 years are considerably less likely to consult with a health professional about their mental health, with a recent Australian study reporting rates of 12.9% for men compared to 21.6% for similar-aged females over 12 months (ABS, 2023b).A key reason for the mental health treatment gap involves men's reluctance to seek help (Johnson et al., 2012;Cleary, 2017;Oliffe et al., 2020), with only a quarter of men indicating they would be likely or very likely to seek help for personal or emotional concerns (AIFS, 2020).A growing body of research has indicated that traditional masculine norms, such as self-reliance, stoicism and avoiding negative emotions (e.g.sadness), may impact male help-seeking patterns (Berger et al., 2013;Yousaf et al., 2015;Seidler et al., 2016;Mahalik and Di Bianca, 2021).For instance, self-reliance may lead men to perceive negative emotions as a sign of weakness and hinder seeking support from friends, family members or professionals (Pirkis et al., 2017).Traditional masculine norms have also been associated with suicidality (Pirkis et al., 2017), poorer health literacy (Milner et al., 2019), poorer mental health outcomes (Wong et al., 2017) and negative attitudes toward seeking mental health support (Levant et al., 2009).
Numerous studies have attempted to identify effective health promotion interventions to improve male help-seeking for mental health difficulties (Sagar-Ouriaghli et al., 2019;Calear et al., 2021;Gilgoff et al., 2023).One such approach involves mental health media campaigns to improve male help-seeking.Media campaigns are organized activities designed to educate, convince or motivate behavior change at a population level.They use messages composed through various communication strategies (Bauman, 2000).A particular benefit afforded by media campaigns involves the publicizing of messages with a specific behavioral focus to large audiences repeatedly over a period of time in an incidental and low-cost way (Wakefield et al., 2010).Mental health campaigns around the world have typically aimed to reach large audiences through varied messaging in different combinations of media such as television, radio, posters, billboards, magazines, newspapers and the Internet (Pirkis et al., 2019;Goodwin and Behan, 2023).While mental health media campaigns exist to educate the general public about a range of mental health-related issues, at the core of many campaigns is the attempt to increase the likelihood that someone experiencing a mental health concern might reach out for help (Niederkrotenthaler et al., 2014;Thompson et al., 2020).Such campaigns often seek to influence help-seeking behaviors through proximal factors such as knowledge, intentions, beliefs, awareness, attitudes, norms, motivation and selfefficacy (Martine et al., 2019).
The strong potential for media campaigns to improve male help-seeking outcomes may be explained through contemporary behavior change theories such as those involving reasoned action approaches (Ajzen, 1991(Ajzen, , 2002;;Fishbein and Cappella, 2006).The theory of reasoned action suggests that a rich set of underlying beliefs involving control beliefs, normative beliefs and behavioral beliefs influence perceived behavioral control or self-efficacy, subjective norms and attitudes.These, in turn, guide the formation of a behavioral intention, subsequently motivating actual behaviors (Ajzen, 1991(Ajzen, , 2002;;Fishbein and Cappella, 2006).Reasoned action may apply within mental health media campaigns targeting male help-seeking by suggesting a causal relationship, whereby media messaging directly affects beliefs at the start of the chain.The shift in beliefs makes help-seeking appear easy to do, socially normative and to lead to good outcomes, thus influencing perceived behavioral control, subjective norms and attitudes toward seeking help.Consequently, these changes may lead to more positive help-seeking intentions that increase the likelihood that a male will access mental health treatment (Fishbein and Cappella, 2006).Media campaigns targeting other areas, such as tobacco use, have been suggested to lead to positive changes in mass populations via these theorized pathways (Wakefield et al., 2010).
Although traditional expressions of masculinity have been challenged and redefined by some men to incorporate more health-enhancing values (Oliffe et al., 2019), certain masculine ideals have been found to hinder engagement in health-promoting behaviors (Mahalik et al., 2007;Gordon et al., 2013).Accordingly, mental health marketing may be unlikely to affect help-seeking outcomes among males who hold to traditional masculine norms that lead them to suppress mental health concerns (Sharp et al., 2022).Several studies have highlighted the need to reframe mental health information to improve help-seeking among men (Rochlen and Hoyer, 2005;Lynch et al., 2018;DeBate and Gatto, 2021).Suggestions include using more humorous, non-stigmatizing language that avoids references to feelings and emotions and makes men feel valued and engaged (Robertson et al., 2018), incorporating solution-focused actions, promoting male qualities such as strength and reframing mental health with other terms such as 'mental fitness' (Lynch et al., 2018) and ensuring messages project a 'sense of control' over mental health issues (DeBate and Gatto, 2021).Despite the need for genuinely male-positive health promotion, risks emerge in attracting men with 'male-friendly' language that reinforces certain aspects of masculinity that result in detrimental health behaviors (Robinson and Robertson, 2010;Fleming et al., 2014).For instance, campaigns that ask men to 'man up', a colloquialism that encourages masculine ideals, may invoke positive action among males seeking to be seen as masculine but have the potential to inadvertently reinforce certain masculine traits (e.g.risk-taking) associated with adverse health consequences (Fleming et al., 2014).Ultimately, the nature and effectiveness of male communication strategies and preferences accommodated across extant mental health media campaigns targeting male help-seeking outcomes remain largely unexplored.
Despite the increasing interest in mental health media campaigns (Clement et al., 2013;Pirkis et al., 2019), there is a paucity of reviews that summarize the effectiveness of media campaigns targeting help-seeking, particularly among males.Some reviews have synthesized the evidence on the effectiveness of a range of interventions (including media campaigns) promoting help-seeking for mental health across various populations (Gulliver et al., 2012;Xu et al., 2018;Bu et al., 2020;Evans-Lacko et al., 2022;Johnson et al., 2022), including men (Seidler et al., 2016;Sagar-Ouriaghli et al., 2019).However, no robust conclusions have been made in these reviews relating to the effectiveness of mental health media campaigns.Other reviews have focused on the effect of media content on a person's decision to seek help for mental health concerns (Goodwin and Behan, 2023) or have included help-seeking as one of several variables of interest in the context of suicide prevention or depression awareness media campaigns (Dumesnil and Verger, 2009;Torok et al., 2017;Pirkis et al., 2019).However, none of these reviews have explored gender-specific findings despite evidence for male-specific communication preferences (Robinson and Robertson, 2010).Only one paper has exclusively examined mental health campaigns for men, but this used a narrative and non-systematic approach and may not capture more recent male views about gender and masculine norms (Rochlen and Hoyer, 2005).Additionally, given the impacts of the COVID-19 pandemic on male mental health (Hadar-Shoval et al., 2022), exploring any recent shifts in male help-seeking responses to mental health campaigns is warranted.Collectively, these studies suggest that media-related interventions and campaigns can play a role in positively influencing mental health-related outcomes, particularly attitudes and intentions toward seeking help.Thus, further evaluation of media campaigns targeting male psychological help-seeking is needed to draw meaningful conclusions for this population.
Therefore, the current review aims to systematically search for studies evaluating media campaigns about mental health and to report on and synthesize their findings about campaign effectiveness on male help-seeking outcomes.

Search strategy
This systematic review was performed according to the guidelines published by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement (Page et al., 2021).Studies were identified through searching three databases, PubMed, PsycINFO via OVID and Scopus, from inception to 31 December 2023, for studies providing evidence on the male help-seeking outcomes of mental health media-based campaigns.Specific search strategies were used for each database, with the search string comprising the following keywords searched by title and abstract and MeSH/Map terms: 'help-seeking' AND 'mental health' AND 'campaign' AND 'media', which included synonyms and closely related words (see Appendix A for an example of search terms used).Only studies in the English language were included in the review.A gray literature search was performed by searching Google for the top 50 hits.The websites of the top health organizations (e.g.National Health Service) and the top three charities (e.g.Beyond Blue) were also searched, and the focus was restricted to three high-income, English-speaking countries (USA, UK and Australia) for feasibility, using similar search terms adapted to fit the search tool.Additionally, efforts were made to locate additional relevant studies through hand-screening the reference lists of studies included in the review.The review protocol was registered in PROSPERO before carrying out the study (CRD42023493822).

Eligibility criteria
Inclusion criteria were based on the PICO (Population, Intervention, Comparison, Outcome) framework.Studies were eligible if they contained either a 100% male sample or a sub-analysis comprising a male group, including comparisons of male and female help-seeking outcomes.No age restrictions were applied.However, studies of people who had already sought professional help were excluded.For this review, exposure could involve any form of an organized media-based campaign primarily targeting mental health issues to improve male help-seeking for mental health difficulties, including mental disorders (e.g.Depressive Disorders), mental distress, suicide or self-harm.Experimental interventions studied by researchers were also eligible to capture data about possible future campaigns.Campaigns that only used or studied non-media elements, such as events or in-person training, were considered ineligible.
Any methodological approach, including qualitative studies, was permitted, provided the study assessed male help-seeking outcomes.Thus, studies were excluded where no data was collected on help-seeking outcomes (e.g.purely descriptive studies with no data on male help-seeking).
Eligible outcome measures could comprise any one or combination of the following: (i) help-seeking attitudes or beliefs about treatments for mental health problems or suicide, including psychological and pharmacological treatments; (ii) help-seeking intentions, including recommending help to others; and (iii) actual help-seeking behaviors, including giving help to others, and formal or informal help-seeking from friends, family, support networks, mental health-related services or professionals and at any stage in the help-seeking engagement process.Information-seeking and help-seeking to obtain knowledge were outside the scope of this review.

Study selection and evaluation
Studies identified through the search strategy were imported into Covidence, and duplicate studies were removed.One reviewer (G.D.) conducted title and abstract screening of all retrieved articles to identify potentially relevant studies.A second reviewer (J.W.) screened at least 20% of retrieved records.A full-text review of potentially relevant studies was conducted independently by the two reviewers (G.D. and J.W.) to determine whether the articles met the eligibility criteria.Any uncertainty about inclusion against the eligibility criteria was resolved through consensus, with a third opinion sought as required (A.M. or N.R.).

Data extraction
After identifying included studies, data were extracted by one reviewer (G.D.) and checked by other reviewers (J.W. or A.M.), including study design, methodology, setting, study sample size, demographics, baseline characteristics, population type, campaign features, duration and mental health issues targeted, outcome measures, findings related to male help-seeking outcomes and any comments (e.g.study limitations).Any uncertainty during data extraction was resolved through consensus, with a third reviewer's (A.M.) input as required.Results were converted into Odds Ratios or Cohen's d effect sizes.Findings from qualitative, quantitative and mixed-method papers were synthesized separately.Qualitative data were summarized narratively, while quantitative data were presented narratively and tabularly.

Study quality
Included studies utilizing a quantitative approach were critically appraised with the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies (Effective Public Health Practice Project, 1998;Thomas et al., 2004;Armijo-Olivo et al., 2012).This allowed for assessing components, including selection bias, blinding, study design, data collection methods, confounds and dropouts, with each area categorized as weak, moderate or strong.An overall quality rating was assigned to each study.Qualitative studies were assessed using the Critical Appraisal Skills Programme (CASP) Qualitative Studies Checklist (Critical Appraisal Skills Programme, 2023).Two reviewers (G.D. and J.W.) independently evaluated all eligible studies for quality, resolving discrepancies through consensus.

RESULTS
Figure 1 outlines the PRISMA flow diagram of the search strategy (Page et al., 2021).The search identified 5414 studies, of which 208 underwent full-text screening and 22 met eligibility criteria and were included in the review.

Campaign evaluation
Seven studies assessed help-seeking attitudes, 12 assessed intentions to seek help and 8 assessed actual help-seeking behaviors.Among all included studies, four (18.2%) assessed more than one type of outcome.There was substantial heterogeneity in the way campaigns evaluated help-seeking outcomes.While three studies (13.6%) used the General Help-Seeking Questionnaire (GHSQ) to measure help-seeking intentions, and three studies (13.6%) used the Attitudes Towards Seeking Professional Psychological Help Scale (ATSPPHS) to measure help-seeking attitudes, the remaining 16 studies (72.7%) used various other measurement tools including self-created scales.

Study quality
As shown in Tables 1 and 2, 2 studies (9.1%) included in this review were rated high quality, with 11 studies (50.0%) rated moderate quality and 9 studies (40.9%) rated low quality, indicating that most studies are at risk of selection bias.

Campaign focus
As shown in Table 3, most campaigns focused on various mental health concerns (6/22; 27.3%) or mental health combined with suicide prevention (5/22; 22.7%).Among them, six studies found an improvement in male help-seeking outcomes (i.e.attitudes, intentions and behaviors), whereas five studies did not find an effect.Concerning depression-specific (4/22; 18.2%) or depression combined with suicide prevention campaigns (2/22; 9.1%), mixed results were also evident.Specifically, four studies revealed an effect, and two others showed no effect on male help-seeking outcomes.Another four studies (18.2%) examined suicide prevention-specific campaigns.Of them, three studies found no effect on male help-seeking, whereas one study did report an improvement (Oliver et al., 2008).No effect was found for the single study (4.5%) targeting alcohol use disorder (Wallhed Finn et al., 2023).

Campaign mode of delivery
Among the primary media channels used in studies were multiple modes (8/22; 36.4%),online modes including Internet advertisements and websites (5/22; 22.7%), video (4/22; 18.2%), print brochures (3/22; 13.6%), billboards (1/22; 4.5%) and social media (1/22; 4.5%).There were mixed results for website-based campaigns on male help-seeking outcomes, with low-quality studies reporting either no within-group effect for an Internet-based game (Burns et al., 2010;Shandley et al., 2010) or no between-group effect for an Internet-based advertisement (Hswen et al., 2022).However, two moderate-quality RCTs of the Man Therapy website found that males viewing either the experimental or control website comprising anonymous screening experienced improvements in their help-seeking outcomes at 12 weeks follow-up (Frey et al., 2023).The other study found that controlling for several covariates, those who viewed the experimental website had greater actual help-seeking behaviors than those in the control condition at 2 weeks' follow-up (Gilgoff et al., 2023).However, such findings should be interpreted cautiously as the study may have broken group randomization due to its analytic approach.Relatedly, a strong-quality ITSA of a social media campaign found an increase in new adolescent and young adult male mental health visits in the post-campaign period (Booth et al., 2018).
Mixed findings were also apparent in campaigns using videos.King et al. conducted two moderate-quality studies of the Man Up documentary (King et al., 2018a,b).They found significant improvements at 4 weeks' follow-up in help-seeking intentions among males viewing a mental health documentary relative to controls (King et al., 2018b).Most male documentary viewers reported qualitative improvements in help-seeking and offering behaviors at follow-up (King et al., 2018a).Conversely, two moderate to low-quality studies found no improvement in male help-seeking at 1-month follow-up measures (Søgaard and Fønnebø, 1995;Braun et al., 2023).
More consistently favorable findings were shown in brochure studies (Doss, 2000;Rochlen et al., 2006;Hammer and Vogel, 2010).Three moderate to low-quality RCTs, showed that males reading brochures had improved posttest attitudes toward seeking professional help (Rochlen et al., 2006;Hammer and Vogel, 2010) or higher amenability to try psychological services at immediate post-test relative to controls (Doss, 2000).In contrast, one billboard study found no effect on help-seeking intentions at post-test (Boucher and Campbell, 2014).
Evaluation of multi-mode campaigns also reported mixed impacts on male help-seeking outcomes.Three strong to moderate-quality studies reported improved male help-seeking outcomes.These comprised campaigns delivered via a combination of advertisements on the radio, websites, newspapers and posters (Cheng et al., 2016) or informational materials, posters, videos and theater shows (Maulik et al., 2019), or billboards, posters and radio advertisements (Oliver et al., 2008).In contrast, two moderate-quality studies of multi-mode campaigns found no improvement in male help-seeking behaviors using a mix of billboards, posters, placards and info screens (Till et al., 2013) or advertisements on television, Internet, posters, pamphlets and videos (Wallhed Finn et al., 2023).Similarly, three low-quality studies found no effect on help-seeking outcomes.These studies used various combinations of media channels, including newspaper articles, radio and television advertisements (Daigle et al., 2006), websites andvideos (Stas et al., 2023) or a documentary, social media, website, radio and newsprint (Schlichthorst et al., 2018).

Campaign intensity
There were mixed findings regarding the intensity of campaign exposure on male help-seeking outcomes.Two categories were assigned.Short exposure involved exposure to the campaign material, typically lasting less than an hour.In contrast, long exposure involved prolonged exposure to campaign materials, typically lasting more than an hour or where there was a possibility of repeated exposure to the campaign.Three moderate to low-quality studies showed that short-intensity campaigns were not effective on male help-seeking.Specifically, one study revealed no within-group effect among males having a single exposure to a brief suicide prevention video (Braun et al., 2023), and two other studies showed no between-group effect for brief messages at post-test (Boucher and Campbell, 2014;Hswen et al., 2022).Help-seeking increases were found for seemingly brief brochures in one low-quality study (Doss, 2000) and two moderate-quality studies (Rochlen et al., 2006;Hammer and Vogel, 2010).Concerning other experimental campaigns using longer-intensity media, King et al. found improvements in male help-seeking across two moderate-quality studies of • USA • Men A new male-sensitive brochure was created to improve the "Real Men.Real Depression" (RMRD) brochure.The brochure described symptoms thought to characterise "masculine depression," used language more compatible with traditional masculine gender roles (e.g., "mental health consultant"; "strategy for attacking"; describing counselling as a cost-effective, solution-focused, client-directed team effort), addressed the misconception about depression as a product of a weak will by citing a medical-model explanation, discussed the cost-effectiveness of proactive counselling versus later medical treatment, and displayed more stereotypically masculine-looking men in the testimonial portraits.
The comparator condition read either: • Belgium • Males aged over 18 years The campaign named "Get out of your head" aimed to improve mental health among men and break the stigma surrounding it and was developed for men who struggle with their mental health or have suicidal thoughts, as well as men who know someone struggling with their mental health.It also consisted of two campaign videos with referral to the campaign website, four video testimonies of men who struggled with their mental health, and a website that included information about mental health and suicide prevention tailored to men.The website also provided information on how to recognise the signs of suicidality, how to take care of yourself and others, how to have a conversation about mental health problems and suicidality, and how to seek professional help and relevant podcasts, books, and other sources of information.
No comparator condition.(King et al., 2018a,b).Similarly, two moderate-quality studies of the Man Therapy website, where participants could view the website multiple times, found an improvement (Frey et al., 2023;Gilgoff et al., 2023).Another long exposure and low-quality experimental online media campaign found no effect (Stas et al., 2023).Neither did the low-quality studies of Reach Out Central, which included long exposure through repeated gameplay messaging throughout the day (Burns et al., 2010;Shandley et al., 2010).Conversely, among publicly accessible campaigns, strong to low-quality studies, where there is a possibility for repeated viewing and prolonged exposure, five found no effect on male help-seeking (Søgaard and Fønnebø, 1995;Daigle et al., 2006;Till et al., 2013;Schlichthorst et al., 2018;Wallhed Finn et al., 2023).In contrast, another four found an improvement in male help-seeking (Oliver et al., 2008;Cheng et al., 2016;Booth et al., 2018;Maulik et al., 2019).

Campaign imagery
A majority (16/22; 72.7%) of studies reported on their use of visual elements in the media-based campaign, where seven used diverse males in their campaign imagery (31.8%).Among studies mainly using male imagery, three moderate to low-quality studies found no within-group effect on helpseeking when viewing videos of males discussing various mental health topics (Schlichthorst et al., 2018;Braun et al., 2023;Stas et al., 2023).At the same time, four moderate-quality studies featured videos and imagery of diverse males, including typically masculine males, mental health professionals, men's health experts, hosts including media personalities or fictitious characters and role models for beneficial health behaviors, such as sharing personal problems with others or seeking help.The results showed that male viewers improved their help-seeking outcomes at follow-up measures (King et al., 2018a,b;Frey et al., 2023;Gilgoff et al., 2023).Similarly, two moderate-quality studies compared campaign media featuring either imagery of males alone or with mixed-gender imagery (9.1%).At post-test measures, Hammer and Vogel found that males viewing masculine-looking men in testimonial portraits when reading a male-specific brochure experienced greater reductions in self-stigma toward seeking help but not help-seeking attitudes when compared to males viewing testimonial portraits of both males and females in a gender-non-specific brochure (Hammer and Vogel, 2010).Contrastingly, Rochlen et al. found no between-group effects in the help-seeking outcomes of males viewing different brochures containing either male-specific imagery or male and female actual or drawn imagery; instead, all conditions led to significant improvements in post-test measures (Rochlen et al., 2006).
Five studies (22.7%) used mixed-gender imagery (i.e.featuring images of men and women), with mixed findings.Among them, three strong to moderate-quality studies found improved male help-seeking outcomes from campaigns that reported using imagery of people sharing their personal stories about mental health not specific to either gender (Cheng et al., 2016;Maulik et al., 2019) or reported using indeterminate gender imagery (Oliver et al., 2008).Despite this, low-quality studies examining the Reach Out Central game, featuring diverse male and female characters, did not find a within-group effect on young male help-seeking outcomes (Burns et al., 2010;Shandley et al., 2010).In the remaining studies, one study (4.5%) reported using a prominent female Olympic athlete as a campaign host, revealing a significant increase in adolescent and young adult male help-seeking behaviors (Booth et al., 2018).Only one study (4.5%) featured no images of people but incorporated imagery depicting positive everyday life experiences.However, it did not show a within-group effect on help-seeking calls among males (Till et al., 2013).The remaining six studies (27.3%) did not use any imagery or did not report imagery used.

Campaign messaging
Substantial heterogeneity of messaging styles was found across different campaigns, with several categories assigned, as shown in Table 4. Five studies (22.7%) primarily used gain-framed combined with male-sensitive language, whereas two studies (9.1%) included gain-framed language but did not target men specifically.Problem-focused framing with male-targeted language was used by three studies (13.6%).Three studies (13.6%) used a combination of gain and lossframed language and targeted men, while two studies (9.1%) used gain combined with loss-framed without a specific male focus.Similarly, another three studies (13.6%) used gainframed language while targeting men.One study (4.5%) used problem-focused with mixed-gender language but did not find a between-group effect (Boucher and Campbell, 2014).Another study (4.5%) used mixed-gender language and found a within-group effect on young males (Booth et al., 2018).The remaining studies could not be categorized based on messaging (2/22; 9.1%).
Mixed results were shown among moderate to low-quality studies with gain-framed and male-sensitive language on male help-seeking outcomes (Doss, 2000;Rochlen et al., 2006;Hammer and Vogel, 2010;Frey et al., 2023;Gilgoff et al., 2023).Doss found that a gender-sensitive brochure describing therapy in various ways, such as that it will not initially focus on emotions, was more effective than a non-gender-sensitive brochure and control condition in producing help-seeking outcomes at post-test measures (Doss, 2000).Nonetheless, Frey et al. found no between-group effect for males viewing the Man Therapy website that contained various approaches, such as framing help-seeking as a strength, than those only viewing an anonymous online screening and referral website (Frey et al., 2023).However, at a 2-week follow-up, a secondary analysis by Gilgoff et al. (Gilgoff et al., 2023) showed that when analyses adjusted for several covariates, males who viewed Man Therapy reported significantly more instances  Problem-focused, male-targeted language (e.g. 'Get out of your head' and featured stories of men struggling with mental health) Søgaard and Fønnebø (1995) Mental illness (non-specific) General public Video (television show) for alcohol use such as gaining respect from others) NR = not reported; Long = longer duration of campaign material exposure (i.e.typically >1 hour) or where there is a possibility for repeated exposure to campaign materials; Brief = short duration of campaign material exposure (i.e.typically <1 hour); Nixed-gender imagery = featuring images of men and women; Gain-framed = focusing on the positive consequences behavior; Loss-framed = focusing on the negative consequences of behavior; Problem-focused = helping men to identify with mental health difficulties; Male-sensitive = incorporates male communication preferences (e.g.humor, solution-focused, avoidance of emotions); Male-targeted = language that focuses on men but does not accommodate their communication preferences; Mixed-gender language = language that is not tailored specifically to men or women.
Table 3. Continued of actual professional behavior but not professional help-seeking behaviors compared to the control website.Conversely, Rochlen et al. found no interaction effect of time by group for men receiving a brochure using male-specific information about depression, male testimonials about depression and male-sensitive language compared to those receiving non-gender-specific brochures (Rochlen et al., 2006).However, when also comparing a gender-specific and non-specific brochure, Hammer and Vogel showed that there was a significant interaction of time by group for help-seeking attitudes in favor of a brochure with male testimonials and male-sensitive language such as language consistent with traditional masculine gender roles (e.g.mental health consultant) and a medical-model explanation for depression (Hammer and Vogel, 2010).Significant increases in male help-seeking behaviors were shown in both studies that appeared to use a mixed-gender focus with gain-framed language, including a campaign that used personal stories about how a psychiatric hospital transformed lives (Cheng et al., 2016) and another campaign featuring the message 'Suicide is preventable.Its causes are treatable.For immediate help call (emergency number)' (Oliver et al., 2008).Whereas all campaigns that used problem-focused approaches with male-targeted language (e.g.encouraging men to identify pain, asking men if they are sad or stories about men with mental health struggles) found no effect on male help-seeking (Daigle et al., 2006;Hswen et al., 2022;Stas et al., 2023).Similarly, none of the moderate-quality studies using male-targeted approaches with gain-framed language (e.g. the benefit of gaining respect from treatment seeking, an adolescent sharing about mastering a past suicidal crisis or indicating that there are many reasons to love life) found a within-group effect on male help-seeking (Till et al., 2013;Braun et al., 2023;Wallhed Finn et al., 2023).
Mixed results were apparent in studies containing both gain and loss-framed messaging together.Three of the five did not find a within-group effect on male help-seeking, including the studies of the single-player Internet game Reach Out Central that sought to teach participants life skills, strategies to improve mood and the consequences of choices made to manage mental health difficulties across real-life scenarios (Burns et al., 2010;Shandley et al., 2010).Despite this, only the two moderate-quality studies by King et al. (King et al., 2018a,b) found significantly higher help-seeking outcomes at follow-up measures among males who watched the documentary relative to controls.In contrast, the study by Schlichthorst et al. (Schlichthorst et al., 2018) of the same documentary found no within-group effect on male help-seeking at post-test measures, which may be attributable to the higher help-seeking baseline scores among viewers of the Man Up documentary.

DISCUSSION
Given the growing research interest in the role of media-based campaigns for public health interventions among males, this review aimed to synthesize the findings about the effectiveness of media-based mental health campaigns on male helpseeking outcomes.To the authors' knowledge, this review is the first to evaluate male help-seeking in the context of mediabased campaigns.While there are promising indications for campaigns using male communication strategies to promote help-seeking, some caution is required in interpreting the results.Included studies tended to be rated low quality, and several did not show positive results.However, methodological limitations may hinder most studies showing null effects, such as small sample sizes, large attrition rates or large differences in group sample sizes.Despite this, the evidence collectively suggests that campaigns targeting mental health or depression can positively influence male help-seeking, including having an immediate effect on actual help-seeking behaviors.Overall, some supportive evidence was found for specific campaign components, including brief exposures to brochure-based campaigns, male or mixed-gender campaign imagery, testimonials and gain-framed messages combined with male-sensitive language as part of the campaign messaging.The results cautiously suggested avoiding other components, including problem-focused language, gain-framed messages targeted at men that do not accommodate their language preferences and brief campaign exposures using delivery modes other than brochures.
Despite the mental health impacts of the COVID-19 pandemic, campaigns run during the 2020-22 years did not affect male help-seeking (Hswen et al., 2022;Braun et al., 2023;Stas et al., 2023).However, it is worth noting that the

Messaging style Definition Example
Gain-framed messaging Language that focuses on the positive consequences of behavior Campaign messaging: 'There are a lot of reasons to love life' (Till et al., 2013) Loss-framed messaging Language that focuses on the negative consequences of behavior Campaign description of a Reach Out Central gameplay scenario: 'If mood is low, making friends is more difficult' (Shandley et al., 2010) Problem-focused language Language that helps men to identify with mental health difficulties Campaign messaging: 'Are you sad?' (Hswen et al., 2022) Male-sensitive language Language that incorporates male communication preferences (e.g.humor, solution-focused, avoidance of emotions) Campaign messaging: 'We are not about feelings, we are about actions' (Doss, 2000) Male-targeted language Language that focuses on men but does not accommodate their communication preferences Campaign messaging: '80% of suicides are committed by men' (Daigle et al., 2006) Mixed-gender language Language that is not tailored specifically to men or women Campaign description: 'The campaign encourages the public to start a dialogue to break the silence around mental illness and to support mental health awareness across Canada' (Booth et al., 2018) causes of male help-seeking appear to have shifted the with studies suggesting help-seeking related to high anxiety than suicide attempts (Moore et al., 2022).Interestingly, none of the campaigns run during the pandemic focused on anxiety conditions, which may explain the absence of help-seeking improvements.Ultimately, more research is needed to ascertain any shifts in male help-seeking reactions to campaigns following the pandemic.
At a campaign focus level, the results indicate some evidence for improvements in male help-seeking among mediabased campaigns addressing mental health and depression with or without suicide prevention.Although there were some exceptions, this may be due to a lack of power in several instances.In contrast, little evidence exists for mediabased campaigns targeting suicide prevention on their own in improving help-seeking outcomes.These findings appear discrepant from other reviews that included male and female populations (Torok et al., 2017;Pirkis et al., 2019).However, studies that did not find an improvement may have also been underpowered.Further research with larger sample sizes is needed to confirm these findings.
When examining the mode of campaign delivery, some evidence was found that multi-channel campaigns can improve help-seeking, but this may not always be the case.Nonetheless, according to Dumesnil and Verger (Dumesnil and Verger, 2009), the impact of multi-channel campaigns may relate to their ability to increase message precision, while their exposure duration may also allow for increased message reinforcement.Despite this, not all included studies were effective when they included extended participant exposure to the campaign materials.Notably, most campaigns that did not show an effect of prolonged exposure duration measured either help-seeking intentions or actual help-seeking behaviors rather than attitudes.This aligns with reasoned action theories, positing that modifying attitudes toward help-seeking via media-based campaigns may be easier than influencing intentions or actual behaviors (Ajzen, 1991(Ajzen, , 2002;;Fishbein and Cappella, 2006).
There was limited evidence that website and video-based campaigns were effective despite being the most common delivery modes.These findings appear discrepant from other review findings that included male and female populations (Goodwin and Behan, 2023) or non-media-based interventions (Sagar-Ouriaghli et al., 2019).As a more traditional mode of health communication (Jansen et al., 2021), the available evidence suggests that brief brochure-based campaigns can improve help-seeking outcomes, consistent with other review findings (Sagar-Ouriaghli et al., 2019).However, some studies may be hindered by poor ecological validity, relying on student samples.Despite this, brochures were key components of all effective brief exposure campaigns, with no evidence suggesting other delivery modes were effective for brief exposures.These results suggest that males may not require repeated or prolonged campaign exposure when the content is more informational, allowing them to process brief materials at their own pace.Informational materials may also be less personal or intrusive and enable males to understand their difficulties in context and discern the possible consequences (Sagar-Ouriaghli et al., 2019).This makes brochures seemingly more conducive to marketing mental health help-seeking to males than other modes.
Among campaigns using imagery, the results indicate that male help-seeking outcomes may be equally influenced by male or mixed-gender imagery.This appears inconsistent with the research suggesting that imagery with females may confuse males reading health-related messages (Ryan et al., 2019).In contrast, positive depictions of males (e.g. in leadership positions) may appeal more to males in health promotion initiatives (Ryan et al., 2019).Given the human tendency to seek schema-congruent information (Meyers-Levy and Tybout, 1989), males adhering to traditional masculine norms may prefer a more masculine presentation of help-seeking that aligns with existing norms about male gender roles (e.g.strength and taking control) to ensure messaging does not threaten their masculine identity (Lynch et al., 2018).However, research is needed to isolate the effects of imagery relative to other campaign elements, as it may be conflated with campaign delivery.
In terms of campaign messaging, combined gain and loss-framed messages appeared to have limited impacts on help-seeking outcomes.In contrast, no evidence was found for the benefits of using problem-focused language.Given the importance of masculine values such as emotional control (Mahalik and Di Bianca, 2021), it is possible that campaigns using problem-focused language may evoke reactance due to a fear of aversive consequences (e.g.having a mental illness) or a perception of the message being a direct challenge to masculine norms.Interestingly, male-targeted and gain-framed messaging were shown to have null effects.This concurs with research showing that some positive messages aimed at increasing help-seeking can have the reverse effect by potentially activating stigmatizing beliefs about helpseeking (Lienemann et al., 2013).
Campaigns that included testimonials or narratives about topics relating to mental health or suicide showed a positive effect on help-seeking in general.This is consistent with other research showing that narrative communication may facilitate better health outcomes due to their ability to exert more persuasive effects (Chang, 2008;Moyer-Gusé and Nabi, 2010;Murphy et al., 2013).Narratives may be perceived as more subtly influential and less condescending than explicit health advocacy efforts with non-narrative approaches (Oschatz et al., 2022), which use evidence-based reasoning and logic to argue a claim (Kreuter et al., 2007).Despite this, two brochure-based campaigns did not find superior effects of brochures containing testimonials compared to non-narrative information.This suggests that narratives may be beneficial but are not necessary to affect male help-seeking outcomes when using brochures.Future research could confirm these findings.
In contrast, campaign effectiveness appears to increase when a combination of gain-framed approaches and male-sensitive language is implemented, with all such campaign messages showing an effect.The effectiveness of gainframed messaging combined with male-sensitive language aligns with recommendations suggesting that positive messaging may assist in destigmatizing help-seeking among males (Lynch et al., 2018).Effective male-sensitive messages appeared to incorporate various language components, including humor, framing help-seeking as strength, appeals to masculine values (e.g.courage), avoiding mentions of feelings and emotions, giving a perceived sense of control over difficulties, non-stigmatizing language (e.g.'masculine depression') and appeals to logic.These promising results on male-sensitive language appear consistent with the broader literature, which recognizes the need to reframe mental health language to gain traction among men and Hoyer, 2005;et al., 2018;DeBate and Gatto, 2021).The success of male-sensitive language may occur through its ability to balance traditional masculinities by including masculine values conducive to mental health (e.g.seeking help is a strength).At the same time, it can also destigmatize mental health by avoiding negative connotations associated with seeking help (e.g.focusing on emotions; Sharp et al., 2022).Despite these potential benefits of male-sensitive language, studies comparing message types did not demonstrate superior effects of male-sensitive relative to mixed-gender messaging and difficulties remain in isolating the specific influence of messaging.Relatedly, campaigns that used mixed-gender language alone or combined with gain-framed messages were shown as effective.Taken together, these results indicate that tailoring messages to males may be beneficial but not necessary to promote male help-seeking.Still, more research is needed to tease out the effects of gain versus loss-framing in the context of help-seeking messaging.
Interestingly, most studies that examined actual helpseeking behaviors found an effect.This indicates that campaigns can affect immediate behavioral changes under the right conditions, even with brief campaign exposures.In the few studies examining multiple outcomes, results were also consistent with the theorized pathways for affecting male help-seeking, with similar results shown across attitudes, intentions or actual behaviors.Despite the role of traditional masculinities in help-seeking outcomes (Seidler et al., 2016), it does not appear that any effective campaigns directly challenged masculine norms to influence help-seeking.If the theorized pathways were in effect, it is possible that effective campaigns were able to alter men's attitudes toward help-seeking by reframing the behaviors to be consistent with traditional masculinities.Alternatively, marketing services that accommodate traditional masculine norms and do not require men to alter their adherence to such norms (Smith et al., 2008).Interpreted this way, reasoned action approaches (Ajzen, 1991(Ajzen, , 2002;;Fishbein and Cappella, 2006) appear to be a promising model for understanding male help-seeking.They suggest that attitude changes may motivate changes along the causal chain and occur without altering adherence to traditional masculinities.

LIMITATIONS
Ultimately, this review's findings should be interpreted with caution given the heterogeneity of included studies, which restricted any discussion of findings to broad generalizations.Additionally, several studies had design limitations and confounding variables, such as the presence of non-media components, and it may not be possible to isolate the effects of campaign messaging from the delivery.While there was some variation in sample characteristics across studies, studies were primarily sourced from high-income countries and relied on convenience sampling.Given that males are not a homogenous group, the results may not be generalizable to other men.There were also diverse approaches to evaluating campaign effectiveness, including commonly used measures (e.g.GHSQ) and self-created scales, which increase the likelihood of measurement error across studies.Furthermore, only some campaigns conducted follow-up measurements beyond three months, which makes it difficult to determine the long-term effects of campaigns on help-seeking outcomes.
Although a reasonable number of studies were identified in the search strategy, the largest study exclusion reason was the absence of male subgroup analysis, revealing a possible selection bias that may hinder this review's external validity.Other relevant studies may have been excluded because of this review's approach (e.g.articles not written in English or the limited screening of retrieved studies by the second reviewer).Also, most included studies could not be considered methodologically robust, with only two included studies assigned a strong-quality rating, which weakens the internal validity of this review's results.It is also worth acknowledging the potential for publication bias (i.e.where studies with null effects are less likely to be published) and issues around a lack of publishing of the results of historical mental-health campaigns, which may impact the validity of this review's findings.

FUTURE DIRECTIONS
Despite some promising indications for the role of media-based mental health campaigns in improving male help-seeking outcomes, the evidence is still equivocal.Thus, there is a need for more high-quality research that carefully evaluates mental health media-based campaigns and the circumstances in which various campaign components are effective for male help-seeking.Future research may also benefit from more theoretically informed approaches to campaign development and rigorous campaign testing before launch to ascertain its effectiveness.This will assist in growing the evidence base for functional campaign components and ensure more cost-effective and targeted campaign development amid greater funding scarcity.Work is also needed to understand the effects of campaigns targeting other specific mental disorders while ascertaining the robustness of the current review's findings.
Drilling down further to determine the optimal campaign components that influence male help-seeking is necessary.Evaluations should also explore the specific elements within campaigns to better isolate the effects of message content, delivery, intensity, focus and visual components, which may otherwise be conflated when assessed collectively, particularly among publicly accessible campaigns where confounds may not be sufficiently controlled.Specifically, research is needed to determine what delivery modes for messages could be used to improve the reach and sustainability of campaign promotions, with few studies examining the effect of social media despite its ability to increase engagement and communication with audiences (Neiger et al., 2012).The anonymity and ubiquity of social media potentially make it a feasible platform for disseminating targeted and repeat messaging over time to vulnerable populations (Torok et al., 2017), and more research is needed into its effectiveness on male help-seeking.
Males are not a homogenous group, and understandably, different male populations will interpret and respond differently to campaigns.Research is needed to determine whether optimal campaign approaches vary for particular male groups.While several included studies targeted younger males, only one appeared to target males aged 40-70 years (Wallhed Finn et al., 2023).Thus, it remains to be explored whether agespecific communication preferences influence the effectiveness of campaigns for older and younger adults, and additional research is warranted.Relatedly, despite the influence of masculine norms on male help-seeking (Levant et al., 2009), only one included study (Rochlen et al., 2006) examined whether adherence to masculine norms moderates the effectiveness of particular messages on male help-seeking outcomes.Thus, the of masculine norms in messaging an area for research with important implications for enhancing male engagement in health-promoting behaviors.

CONCLUSIONS
The current review indicates that media-based campaigns as a health promotion avenue can positively impact male help-seeking when addressing mental health or depression.However, the results should be interpreted with caution due to limitations in isolating the effects of campaign messaging from delivery and issues with heterogeneity of campaign approaches.Emerging evidence was found for using male or mixed-gender imagery, brochure-based campaigns and certain gain-framed messages such as those combined with male-sensitive language.There is an opportunity to develop future health promotion campaigns that optimize messaging and delivery tailored to such preferences to improve male help-seeking.Additional targeted studies evaluating the effectiveness of various components within media-based campaigns would assist with enhancing the evidence-based on interventions to improve male help-seeking for mental health.

ETHICS
An ethics statement is not applicable because this study is based exclusively on published literature.
everyday life experiences (e.g. a child's drawing, a restaurant menu, a postcard from a friend) Male-targeted, gain-framed language (e.g.'There are a lot of reasons to love life.If you are currently unable to find a reason: Call (hotline) and let's talk about it!')WallhedFinn et al.

Table 1 .
Characteristics of Studies Included in the Review

Author (Date) Study type Objective Country and Population description Campaign/ intervention description Comparator Duration (Campaign type) Study sample (Males)
nications company Bell Canada and hosted by a prominent Canadian female athlete who publicly shares their lived experience of depression to encourage the public to start a dialogue and support mental health awareness by interacting with the campaign's digital markers via social media (e.g., retweets, hashtags) and making calls and texts on the Bell Canada network, of which generated donations promised by Bell Canada.The primary goal of the 2012 campaign was to invite Canadians to talk about mental health in an effort to break down the stigma that prevents many from seeking help.aged 15 to 19 years that features a 17-yearold boy sharing his personal story about a suicidal crisis, the factors that led to it, and how he came through it, noting the relevance of proactive help-seeking, and highlighting different sources of help (i.e., teacher, friends, and professional help).A list of mental health services for youth was presented at the end of the video.The video was similar in production and style to the control video.single-player game that is not a structured treatment but incorporates principles of cognitive behavioural theory.It seeks to teach life skills to players, such as problem-solving, optimistic thinking, and communication, by using real-life scenarios in a virtual setting.The game allows players to measure positive affect and track their mood over time to learn the effect of different strategies for improving their mood (e.g., sleep).Players interact with several non-playing characters and are also taught the consequences of choices made to manage mental health difficulties as they engage with several real-life scenarios and have to select from different options.The game explores several themes, including mental health difficulties and relationship problems.ROC was developed in consultation with other young people aged 16 to 25 years.aimed to educate the general public about mental health challenges, reduce stigma, and improve access to services and information at the Centre for Addiction and Mental Health (CAMH), a psychiatric hospital in Toronto, Canada.The campaign included personal stories about addiction and mental illness to highlight how CAMH transformed lives.It was advertised on radio, websites, newspapers, and in different transport locations in downtown Toronto.Table 1.Continued Author (Date) Study type Suicide Prevention Week (SPW) is a media campaign that aims to change the behaviours of males with suicidal ideation and the public will in Québec, Canada.The SPW 2000 campaign also sought to have the target population adopt the attitude that men have the right to feel pain and, therefore, to seek help.It also included activities such as local community meetings and conferences at schools, colleges, and industries.

Table 1 .
ContinuedThe impact of media-based mental health campaigns on male help-seeking

Table 1 .
ContinuedThe impact of media-based mental health campaigns male help-seeking

Table 1 .
Continued the 3-hour-long documentary Man

Table 2 :
The CASP quality assessment tool for qualitative studies

Table 3 :
Campaign features of studies included in the review

Table 4 :
Campaign messaging category definitions